New to neuro/TBI/hypothermia

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Taking care of a pt for the past couple days and want some advice on what could've been done differently or not, for the sake of learning purposes....

This pt had a TBI, was having pupillary changes 3rd day hospitalized and started on hypothermia protocol...was on it for a week, managed ICP with mannitol q6, 3% drip, and 23% PRN...a week later a crani/bone flap was done to help with the ICP...next day, hypothermia D/C'd, nimbex off, slowly rewarming pt at 7am, cough/gag intact, pt partially blinking, spont breathes, 6pm pt at goal temp. Next day, 7am pupillary changes more and more frequent, MRI ordered, pt starts deteriorating fast.....unable to use previous drips as sodium was critically high. End of shift patient herniates, pupils fixed and dilated, all reflexes lost.

We only do hypothermia protocol for pts post cardiac arrest. That is, we cool them down to 91.7 - if that's what hypothermia your talking about.

Craniectomy within the first 24-48 hours is what our neurosurgery and neurology teams push for.

Did the pt have an Evd or bolt? I would assume so with the aggressive care, seemed all measure were given. Paralytics, 3 percent, mannitol - I guess the next step would be pentobarb coma and lobectomy. Did the do a lobectomy?

I hope the patient wasn't brought to mri with high icps, that could of pushed the patient over the edge...

We only do hypothermia protocol for pts post cardiac arrest. That is, we cool them down to 91.7 - if that's what hypothermia your talking about. he was cooled to 92degrees his 3rd day admitted because he was showing pupillary changes

Craniectomy within the first 24-48 hours is what our neurosurgery and neurology teams push for. Crani/bone flap was done a week later. I'm still trying to figure out why they waited so long?

Did the pt have an Evd or bolt? I would assume so with the aggressive care, seemed all measure were given. Paralytics, 3 percent, mannitol - I guess the next step would be pentobarb coma and lobectomy. Did the do a lobectomy? They didn't do a lobectomy. No bolt or EVD

I hope the patient wasn't brought to mri with high icps, that could of pushed the patient over the edge...7/1 The Dr. ordered us to get the MRI done asap, knowing his ICP was in the 20-30s. We did give mannitol before going to MRI. 7/2 After the Crani was done, the hummingbird was removed, the next day we went to CT, so no way of knowing the ICP. 7/3 MRI was again done the day after CT with the hummingbird removed during the crani.

I personally never saw hypothermia used in TBI but I have read about it and the therapy is typically used immediately after the injury not days. I have seen neuro wait several days before doing a crani or bone flap, sometimes the extent of the damage is minimal but quickly increases leading to a cran.. As far as your question if anything else could have been done, well that is hard to say because I was not with the pt from day one. Our neuro docs tend to do daily CT's or STAT ones for neuro changes to monitor the injury. A means to intervene quicker.. Sounds as tho this TBI was in fact very bad and little could have been done to save him much less have some kind of quality of life.. The bone flap allows the brain to swell to minimize damage, in this case; it did not work which leads me to believe the damage was great..I know it is hard but sometimes death is the nicest thing to happen.

Yeah hard to say anything could have been done differently. Like people have said maybe a trip to CT instead of MRI to just get a quick picture. Maybe an EVD but doesn't mean it would changed anything.

Sounds like with pupillary changes so early on, probably not a whole lot you coulda done. Also in my experience, Ive only done hypothermia protocol on patients s/p cardiac arrest. Unfortunately it would had been difficult to see s/s of pending herniation if patient was cooled bc heart rate when cooled usually drops to 50's anyway. I agree, bone flap sooner maybe...